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Rapid sequence intubation (RSI) of anesthesia is sometimes referred to as a “crash” intubation. The definition of RSI is the near simultaneous administration of a neuromuscular blocking drug and a sedative to induce unconsciousness and paralysis for endotracheal intubation. It has become a safe and effective method of establishing emergent airway control in patients with suspected life-threatening emergencies. It ensures optimal patient compliance in the best possibly controlled environment that can be achieved in the Emergency Department (ED). RSI in its classical description involves preoxygenation followed by the near simultaneous administration of a potent sedative-hypnotic agent and a neuromuscular blocking agent, application of cricoid pressure, avoidance of positive-pressure ventilation by mask, and intubation with a cuffed endotracheal tube.1-21 Various pretreatment drug regimens have been advocated to prevent the potentially deleterious side effects of aspiration of gastric contents, cardiovascular excitation or depression, and intracranial pressure elevation.

The first endotracheal tubes were developed for the resuscitation of the newborn and victims of drowning in the 19th century but were not used in anesthesia until 1878.13 Muscle relaxants were not prepared until some 60 years later. Succinylcholine was prepared by the Nobel Laureate Daniel Bovet in 1949, after which it gained the widespread usage it still enjoys today. The RSI technique did not come into modern-day practice until the end of World War II.

Patients can be hypoxic, confused, uncooperative, unstable, and unknowing of their medications or medical conditions and can require airway control within minutes of arrival at the ED. RSI is the preferred method for securing the airway in the ED, as these patients are at risk for aspiration. These risks include vomiting from gastrointestinal obstruction, opioids, or hypotension; regurgitation from diabetic gastroparesis, gastroesophageal reflux, increased gastric pressure, or decreased lower esophageal sphincter tone; impaired laryngeal protective reflexes; and difficult airway management.7 Conditions such as recent meal ingestion, pain, obesity, and pregnancy place patients at higher risk as well.

The procedure of RSI has many steps. It is sometimes easier to remember the 10 P’s of RSI: plan, preparation (of drugs, equipment, and people), protect the cervical spine (if indicated), positioning (can be done after paralysis), preoxygenation, pretreatment (e.g., atropine, fentanyl, lidocaine), paralysis, protection (i.e., Sellick’s maneuver), placement (endotracheal tube and confirmation of its position), and postintubation management. The controversy surrounding the technique (e.g., cricoid pressure effectiveness and ventilation prior to intubation) and the role in preventing aspiration has been questioned.22-25 This has contributed to the lack of standardization.22-25 Despite this, RSI has currently achieved a status close to being a standard of care for ED intubation in patients with full stomachs.24


The primary indication for RSI is to quickly protect and secure the patient’s airway, preventing regurgitation of gastric content, and preventing aspiration. The rationale behind RSI is to create an environment in which the trachea ...

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